Risk factors for prospective increase in psychological stress during COVID-19 lockdown in a representative sample of adolescents and their parents
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BJPsych Open (2021)
7, e94, 1–7. doi: 10.1192/bjo.2021.49
Risk factors for prospective increase in
psychological stress during COVID-19 lockdown
in a representative sample of adolescents and
their parents
Kerstin Paschke, Nicolas Arnaud, Maria Isabella Austermann and Rainer Thomasius
Background psychological stress. Risk factors for increased psychological
COVID-19 lockdown measures imposed extensive restrictions stress included sociodemographic (e.g. female parents, severe
to public life. Previous studies suggest significant negative financial worries) and emotion regulation aspects (e.g. non-
psychological consequences, but lack longitudinal data on acceptance of emotional responses in parents, limited access to
population-based samples. emotion regulation strategies in adolescents), explaining 31% of
the adolescent (Nagelkerke R2 = 0.31) and 29% of the parental
Aims (Nagelkerke R2 = 0.29) model variance.
We aimed to prospectively identify increased psychological
stress and associated risk factors in parent–child dyads. Conclusions
This study is the first to prospectively show an increase in psy-
Method chological stress during COVID-19 lockdown in a representative
We conducted a prospective, observational online study on family sample. Identified demographic and psychosocial risk
a representative German sample of 1221 adolescents aged factors lead to relevant implications for prevention measures
10–17 years and their parents. Psychological stress and psy- regarding this important public health issue.
chosocial variables were assessed before the pandemic (base-
line) and 1 month after the start of lockdown (follow-up), using Keywords
standardised measures. We used multilevel modelling to Psychological stress; COVID-19 lockdown; adolescents; parents;
estimate changes in psychological stress, and logistic regression risk factors.
to determine demographic and psychosocial risk factors for
increased psychological stress. Copyright and usage
© The Author(s), 2021. Published by Cambridge University Press
Results on behalf of the Royal College of Psychiatrists. This is an Open
The time of measurement explained 43% of the psychological Access article, distributed under the terms of the Creative
stress variance. Of 731 dyads with complete data, 252 adoles- Commons Attribution licence (http://creativecommons.org/
cents (34.5%, 95% CI 31.0–37.9) and 217 parents (29.7%, 95% CI licenses/by/4.0/), which permits unrestricted re-use, distribu-
26.4–33.0) reported a significant increase in psychological stress. tion, and reproduction in any medium, provided the original work
Baseline levels were lower than in dyads without increased is properly cited.
The COVID-19 pandemic represents a major crisis that threatens Initial studies support the notion of the COVID-19 pandemic
physical and mental health. It places significant psychological being perceived as a stressful experience on a population level.8 One
burden on societies and individuals across the world.1 In the first cross-sectional study identified 38% of the Italian general population
weeks of the pandemic, many countries adopted public measures as having experienced significant distress during early lockdown.9
based on social distancing, to slow down the human-to-human Psychosocial conditions of children and their parents have long
spread of the novel virus. In mid-March 2020, the German played a subordinate role in the public debate during the COVID-
Government legislated the nationwide closure of schools, child care 19 pandemic.1,10 To the best of our knowledge, no studies are available
facilities, sports venues and public playgrounds, along with the impos- that have investigated psychological stress before and during the
ition of massive contact restrictions (termed ‘lockdown’).2 By that COVID-19 pandemic in representative family samples. Although
time, Europe was the epicentre of the pandemic. By mid-April, 977 stress increase in populations facing large-scale stressful events
569 cases and 84 607 COVID-19-associated deaths were reported in seems to be self-evident, such an approach is necessary to better
Europe. The most cases occurred in Spain (n = 172 541), Italy (n = understand the effects of an event unpredictable in duration.1,6,10
162 488) and Germany (n = 127 584). Among these countries, the Assessing the subjective appraisal of threatening or challenging
death rate was lowest in Germany at that time (2.56%, compared events in light of available coping resources (individually perceived
with 12.97% in Italy and 10.46% in Spain).3 Case fatality rates could stress), rather than life events per se (objective stress), could be
be shown to positively correlate with fear of the disease.4 Besides shown to be superior in terms of predicting health and health-
fear of death, severe lifestyle transformations, including decreased related outcomes.11 Global stress perception thus depends on context-
social contacts and upended daily structures, were associated with ual and personal factors, such as gender; age; educational, economical
higher depression and anxiety rates in adolescents.5 This is supported and occupational background;12 emotion regulation capabilities13 and
by studies from previous virus outbreaks that indicate containment parental self-efficacy.14
measures, such as quarantine, isolation and social distancing, can
have extensive negative consequences for mental health.6 Moreover,
the resulting high-density conditions (i.e. household crowding) are Aims
known to be particularly stressful and even traumatising to a signifi- To better identify those particularly vulnerable and thus in need of
cant proportion of children and parents.2,6,7 future targeted preventive action, this study aimed to assess
1
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prospective levels and potential risk factors of psychological stress in Questionnaire (Fragebogen zur Selbstwirksamkeit in der Erzie-
adolescents and their parents, from the general population in hung).14 Adolescents’ and parents’ emotion regulation problems
Germany. We relied on standardised, longitudinal subjective were assessed by the short form of the Difficulties in Emotion Regu-
ratings of psychological stress before and during the COVID-19 lation Scale,16 a standardised 18-item tool organized into six sub-
pandemic, and expected that (a) a relevant proportion of adoles- scales (non-acceptance of emotional responses, lack of emotional
cents and/or parents will report an increase in psychological stress clarity, difficulties engaging in goal-directed behaviour under
during COVID-19 lockdown compared with pre-COVID-19 pan- unpleasant emotions, impulse control difficulties, limited access to
demic baseline measures; and (b) increases in psychological stress emotion regulation strategies and [lack of] emotional awareness).
can be predicted by a prespecified set of sociodemographic vari- Behavioural avoidance was measured with the four-item Procrastin-
ables, such as gender and financial worries, as well as potentially ation Questionnaire for Students (Prokrastinationsfragebogen für
modifiable family-related and stress coping-associated factors, Studierende).17 This questionnaire was initially validated in
such as emotional dysregulation and behavioural avoidance (i.e. German university students via online questionnaire. Because of
procrastination). the simple item structure with a five-point Likert-scale response
((almost) never to (almost) always) and its relation to study assign-
ments (e.g. ‘I put off starting tasks until the last moment’), it has
Method been frequently applied to high school students in clinical settings.
This is supported by an excellent internal consistency for the present
Participants and procedure adolescent sample (Cronbach’s α = 0.90). Moreover, during follow-
A representative sample of 1221 German adolescents aged between up, parents and adolescents were asked whether they mainly stayed
10 and 17 years, and 1221 respective parents, were included in this at home during COVID-19 lockdown.
observational study, using an online battery of questionnaires (N = The change in psychological stress from baseline to follow-up
2242). Of those, 824 parent–child dyads (67.5%) consented to join measurement was the primary outcome assessed by the Perceived
the follow-up measurement (n = 1648). Representativity was Stress Scale (PSS-4).11 This four-item instrument has been validated
assured in terms of proportions of gender, age and region of resi- in large international samples,12 including adolescents,18,19 and was
dence by using a random sampling method from the well-established applied at baseline and follow-up. Participants rated how frequently
German market research and opinion polling company forsa they have appraised their life as unpredictable, uncontrollable and
Gesellschaft für Sozialforschung und statistische Analysen mbH overloading within the previous month. Likert-scale responses
(for details see the study by Paschke et al,15 and Supplementary were summed up to a score of 0–16, with higher scores indicating
Methods and Supplementary Fig. 1 in Supplementary Appendix 1, higher general stress. A score of ≥ 8 could be referred to as
available at https://doi.org/10.1192/bjo.2021.49). The baseline data elevated.20
was collected as part of a large online survey on psychological
stress and media usage in families on a population basis, and supple-
Statistical analysis
mented by follow-up measurements at approximately half-year
intervals. The first interim results of an ongoing longitudinal study Absolute and relative frequencies were computed together with
are presented here. The observational period was set between 13 95% confidence intervals for categorial variables, and mean values
and 27 September 2019 for baseline, and between 20 and 30 April with s.d. for metric variables. Sociodemographic and psychological
2020 for the first follow-up assessment, 1 month after the start of characteristics of the baseline and the follow-up adolescent and par-
the German COVID-19 lockdown. ental sample were compared with χ2- and t-tests for categorial/
The authors assert that all procedures contributing to this work metric variables, to account for the sample attrition. Equivalence
comply with the ethical standards of the relevant national and testing was performed to compare mean baseline PSS-4 scores
institutional committees on human experimentation and with the with the literature by calculating two one-sided tests (TOST; for a
Helsinki Declaration of 1975, as revised in 2008. All procedures detailed description refer to the Supplementary Methods in
involving humans were approved by the Local Psychological Ethics Supplementary Appendix 1). To investigate the potential change
Committee of the University Medical Center Hamburg-Eppendorf of mean PSS-4 scores, paired-sample t-tests were computed. Effect
(ethical approval number LPEK-0145). Informed consent was sizes were calculated by Cohen’s d for repeated measures (drm).
obtained from all participants. Pearson correlation tests were used for PSS-4 values of parents
and adolescents at baseline and follow-up. Correlation values were
statistically evaluated using a z-test and Cohen’s q for effect size
Measures and outcome estimation.
We collected sociodemographic data on gender, age, place of resi- PSS-4 values of adolescents and corresponding parents were
dence, educational and first-generation migration background, estimated in a multilevel model, with the measurement time point
parental partnership status and the number of underaged children as an independent variable. Random effects were accounted for by
in the household at baseline. Occupation (‘Which of the following considering participants and their nesting within parent–child
descriptions of your occupation most closely applies to you?’ – dyads. To reveal the effect of between-group variance resulting
example answers: ‘not employed’, ‘job-seeking’ versus ‘part-time from measurements before and during the COVID-19 pandemic,
employed’, ‘fully employed’), school attendance (‘What are you cur- the intraclass correlation coefficient was calculated.
rently doing? Are you still in school, are you in training, are you Based on the individual’s change in psychological stress, the
employed or what else do you do?’) and financial worries (‘Which samples of adolescents and parents were each divided into two
of the following statements about your financial situation applies groups: group 1 showed an increase in psychological stress by >3
most to you?’ – ‘I often worry about paying my bills’, ’ I/my points (1 s.d.) and group 2 showed no increase in psychological
child often have to do without something because I have to limit stress. The sociodemographic characteristics and total scores of
myself financially’ versus ‘I have enough money for everything I the psychological measures for these groups were compared by
need’, ‘I have enough money to save something each month’) χ2- and t-tests (categorial/metric variables) and multivariate analysis
were measured by single items. Moreover, confidence in parenting of variance (psychometric variables), with separate post hoc Scheffé
was assessed with the validated nine-item Parental Self-efficacy tests for adolescents and parents. Effect sizes were computed with
2
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Cramer’s V (categorial variables) and Cohen’s d (metric variables) Table 1 Sociodemographic sample description
for independent measures.
Follow-up sample, n (%) or
Logistic regression analyses were used to determine risk factors Variables/categories mean (s.d.; range)
for increased psychological stress in adolescents and parents during
Adolescents 824
COVID-19 lockdown, controlling for potential age and baseline Gender
psychological stress effects. Respectively, the sociodemographic Male 442 (53.6)
and psychological baseline measures, time spent at home during Female 382 (46.4)
COVID-19 lockdown and an increase in psychological stress (yes/ Age, years 13.06 (2.4; 10–17)
no) of the corresponding parent/child were simultaneously (Prospective) school-leaving certificatea
No/low educational degreeb 30 (3.8)
entered into multivariate regression models, with age and PSS-4
Middle or higher educational degreec 762 (96.2)
baseline as covariates after dichotomising. Model reduction was High school studentd
performed by backwards elimination using the Akaike information Yes 763 (92.7)
criterion. Adjusted odds ratios were estimated based on the final Noe 60 (7.3)
model (for further details refer to the Supplementary Methods in Parents 824
Supplementary Appendix 1). Gender
All statistical analyses were performed with the software Male 405 (49.2)
Female 419 (50.9)
package R version 4.0.2 for Windows.21
Age, years 46.5 (8.0; 28–75)
Highest educational levelf
Low educationg 73 (8.9)
Results Middle or high educationh 750 (91.1)
Occupation
Sample characteristics Full-time or part-time employment 733 (89.0)
No employment 91 (11.0)
A comparison between the baseline and follow-up sample, regard- Relationship statusi
ing sociodemographic factors and psychometric responses to Single 63 (7.7)
account for potential attrition effects, did not reveal any significant Partnership 759 (92.3)
differences (Supplementary Table 1 in Supplementary Appendix 1). Parent–child dyad
Number of underaged children in 1.7 (0.83; 1–13)
Of the 824 dyads that participated in the baseline and the follow-up
householdj
measurements, 731 sufficiently completed the PSS-4 and could be Place of residence
included in the family-based analyses (Supplementary Fig. 1 in Urban living 440 (53.4)
Supplementary Appendix 1). Rural living 384 (46.6)
Table 1 shows the sample characteristics. The adolescent sample Financial worriesk
was 46.4% female. The adolescents’ mean age was 13.06 (s.d. 2.40). Yes 33 (4.1)
The adolescents showed mean PSS-4 values of 5.53 (s.d. 3.02) before No 782 (96.0)
First-generation migration backgroundl
the pandemic and 6.93 (s.d. 3.14) during COVID-19 lockdown. A
Yes 36 (4.4)
paired t-test revealed a clinically significant increase in psycho- No 787 (95.6)
logical stress in adolescents (t(823) = 11.44, P < 0.001, Cohen’s
a. No answer, n = 32.
drm = 0.41). The parental sample was 50.9% female. The parents’ b. No, special school (Förderschulabschluss) or lower school certificate
mean age was 46.5 (s.d. 8.0). The parents showed mean PSS-4 (Hauptschulabschluss).
c. Secondary school certificate (Realschulabschluss) to university entry qualification
values of 5.33 (s.d. 2.98) before the pandemic and 6.33 (s.d. 2.99) (Abitur).
d. No answer, n = 1.
during COVID-19 lockdown. Comparable with the adolescents, a e. In voluntary service, apprenticeship, national service or job-seeking.
paired t-test showed a clinically significant increase in psychological f. No answer, n = 1.
g. No or lower school certificate (Hauptschulabschluss).
stress in the parental sample (t(823) = 9.13, P < 0.001, Cohen’s h. Secondary school certificate (Realschulabschluss) to doctor’s degree (PhD).
drm = 0.32). i. No answer, n = 2.
j. No answer, n = 4.
The parental PSS-4 baseline value was equivalent to the average k. No answer, n = 9.
score of large samples of 37 451 European participants (mean differ- l. No answer, n = 1.
ence of 0.1, TOST 90% CI −0.08 to 0.28).14 The adolescent baseline
score was 1.2 points lower than the PSS-4 total score of a large sample
of 29 388 British adolescents (mean difference of 1.2, TOST 90% CI different trajectories of psychological stress development are visua-
1.01–1.39).15 A younger British sample showed an equivalent value lised in Fig. 1.
(mean difference of 0.1, TOST 90% CI −0.17 to 0.23).16 Please
refer to the Supplementary Results in Supplementary Appendix 1 Adolescents
for further details. A total of 252 adolescents (34.47%, 95% CI 31.03–37.92) reported
an increase in psychological stress from baseline to follow-up.
Psychological stress before and during the pandemic These adolescents showed significantly lower PSS-4 values before
the pandemic (4.36 v. 6.81, t(609.54) = −12.79, P < 0.001, d = 0.93)
PSS-4 values of adolescents and their respective parents showed
and significantly higher values during COVID-19 lockdown, com-
moderate correlations at baseline (r = 0.38, P < 0.001) and slightly
pared with adolescents who did not experience increased stress
higher (moderate) correlations at follow-up (r = 0.45, P < 0.001;
(9.15 v. 6.22, t(537.48) = 14.46, P < 0.001, d = 1.10), with large
comparison: z = 3.24, Cohen’s q = 0.17). A multilevel analysis of
effect sizes.
the PSS-4 values of all participants, taking into account the
parent–child dyads, revealed an intraclass correlation coefficient
value of 0.43 (Supplementary Table 2 in Supplementary Appendix Parents
1). This indicates that 43% of the PSS-4 variance is explained by A total of 217 parents (29.69%, 95% CI 26.37–33.00) experienced an
the time of the measurement (follow-up 1 month after start of increase in psychological stress during COVID-19 lockdown.
COVID-19 lockdown versus baseline 7 months earlier). The They showed significantly lower PSS-4 values before the pandemic
3
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2.33, 95% CI 1.56–3.49), procrastination (adjusted odds ratio 2.10,
15
95% CI 1.27–3.48), limited access to emotion regulation strategies
(adjusted odds ratio 2.01, 95% CI 1.21–3.35) and mainly staying
at home during COVID-19 lockdown (adjusted odds ratio 1.65,
95% CI 1.08–2.50). High emotional awareness served as a protective
factor for adolescents, with an adjusted odds ratio of 0.47 (95% CI
0.29–0.77).
Psychological stress (PSS total score)
Parents
10 Ten out of nineteen predictors and the two covariates (baseline psy-
chological stress and age) stayed in the logistic regression model
after backwards elimination for the parents (Supplementary
Table 6 in Supplementary Appendix 1). The remaining variables
explained 29% of the final parental model variance (Nagelkerke
R2 = 0.29). Significant parental risk factors for increased psycho-
logical stress could be identified, including female gender (adjusted
odds ratio 1.86, 95% CI 1.29–2.76), partnership status (adjusted
5 odds ratio 2.78, 95% CI 1.10–6.98), urban living (adjusted odds
ratio 1.45, 95% CI 1.00–2.10), financial worries (adjusted odds ratio
1.86, 95% CI 1.08–3.19), increased psychological stress of the corre-
sponding adolescent (adjusted odds ratio 1.59, 95% CI 1.09–2.33),
procrastination (adjusted odds ratio 1.70, 95% CI 1.00–2.89) and
non-acceptance of emotional responses (adjusted odds ratio 3.02,
95% CI 1.78–5.13).
All adjusted odds ratios are visualised in Fig. 2.
0
pre-COVID-19 under lockdown Discussion
Time of measurement
To our knowledge, this is the first study to investigate psychological
Fig. 1 Multilevel analysis: trajectories of psychological stress stress within a representative sample of adolescents and their
before the COVID-19 pandemic and under lockdown measures. The parents during COVID-19 lockdown, compared with pre-
individual trajectories of all adolescents and parents are shown, COVID-19 conditions, in a longitudinal design. A total of 43% of
together with means and 95% confidence intervals of individuals the psychological stress variance in the parent–child dyads could
belonging to the increased psychological stress group and non- be explained by the time of measurement (September 2019 versus
increased psychological stress group, in reference to the two April 2020). We found that about a third of the adolescents and
measurement points. The size of the dots reflects the group size. parents showed a significant increase in psychological stress
Accordingly, smaller dots represent the increased psychological
during COVID-19 lockdown. Although increased psychological
stress group and larger dots represent the non-increased
stress seems to be a normal human reaction to the COVID-19 pan-
psychological stress group.
demic,6 this finding appears meaningful from a public health per-
spective because psychological stress is a major predisposing
factor for health problems, including (neuro-)psychiatric seque-
(3.74 v. 6.00, t(546.91) = −11.13, P < 0.001, d = 0.80) and signifi- lae.22,23 This is of particular importance in adolescents, given their
cantly higher values during COVID-19 lockdown (8.33 v. 5.51, increased vulnerability to stress and psychopathology in a period
t(427.98) = 13.41, P < 0.001, d = 1.06), compared with parents who of substantial neurobiological and psychological changes.24 The
did not experience increased stress, again with large effect sizes. finding builds on initial cross-sectional studies from Germany,25
A detailed comparison on sociodemographic and psychological Italy9 and China,26,27 showing that about a quarter of German, a
parameters, including results of the multivariate analyses of vari- third of Italian and up to half of Chinese adults reported feelings
ance and post hoc tests (psychometric variables) between groups of mental distress during the initial stage of the COVID-19
with and without increased psychological stress, can be found in pandemic.
Supplementary Appendix 1 (Supplementary Results and Supple- Interestingly, baseline psychological stress level could be identi-
mentary Tables 3 and 4). fied as a major factor that needs to be considered when investigating
potential stress increase. Adolescents and parents who experienced
a significant increase in psychological stress had lower baseline
Risk factors for increase in psychological stress
stress levels than those who did not experience increased psycho-
Adolescents logical stress during COVID-19 lockdown. This might suggest
Six out of fifteen predictors and the covariate baseline psychological that the latter group has better developed stress-coping mechanisms
stress (covariate age excluded) stayed in the logistic regression than those with lower baseline stress.28 On the other hand, albeit
model after backwards elimination for the adolescents hypothetical at the present stage of research, COVID-19 lockdown
(Supplementary Table 5 in Supplementary Appendix 1). The consequences, such as school closures and home office implementa-
remaining variables explained 31% of the final adolescent model tion, might actually be stress-reductive among a subsample of ado-
variance (Nagelkerke R2 = 0.31). Significant adolescent risk factors lescents and parents. Correspondingly, family cohesion and better
for increased psychological stress included financial worries family adjustment could be promoted, and school-related problems
(adjusted odds ratio 2.13, 95% CI 1.29–3.51), increased psycho- (like low academic achievement, experiencing social pressure or
logical stress of the corresponding parent (adjusted odds ratio being bullied) might decrease.29
4
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No stress increase Stress increase Adolescents Parents
Odds ratio [95% CI] P-value Odds ratio [95% CI] P-value
Urban living e e 1.45 [1–2.1] 0.05
Model
Low (prospective) education Adolescents e e 1.7 [0.86–3.33] 0.13
Parents
Female gender e e 1.89 [1.29–2.76] 0.001
Procrastinationa 2.10 [1.27–3.48] .004 1.7 [1–2.89] 0.05
Non-acceptance of emotional responsesb e e 3.02 [1.78–5.13]Paschke et al
stress, and parents with a low acceptance of emotional responses by COVID-19 and lockdown-induced economic changes. This
were three times as likely to experience increased psychological was not the primary aim of the study and is a complex issue, as
stress. Moreover, procrastination – an avoidance-based, short- research shows that youth stress responsiveness is a highly volatile
term emotion regulation strategy36 – could be identified as a risk construct, affected by numerous family-related, developmental and
factor for adolescent (adjusted odds ratio of 2.10) and parental other biopsychosocial aspects.41 Nevertheless, based on prior research,
increased psychological stress (adjusted odds ratio of 1.70). In con- we can assume that the COVID-19 pandemic was a significant source
trast, emotional awareness (the appraisal and recognition of one’s of stressors in the current sample, allowing for conclusions on a popu-
own feelings) could be identified as a potentially modifiable psycho- lation level.42 Finally, it should be kept in mind that the reported
logical protective factor against increased psychological stress in results are from an ongoing study. Thus, the added value of prospect-
adolescents (adjusted odds ratio of 0.47). Aside from external ive studies by means of multiple measurement points has not yet been
factors, cognitive appraisal processes determine whether and how fully exploited.
much a situation is perceived as stressful, triggering coping strat-
egies such as emotion regulation to reduce negative feelings.37
Considering intraindividual difficulties in emotion regulation can Clinical relevance and future research
help to understand interindividual differences in psychological This prospective observational study is the first to report on the
stress during COVID-19 lockdown measures, thereby providing increase in psychological stress in adolescents and their parents,
potential anchors for prevention approaches at individual and as well as associated demographic and psychosocial risk factors in
family levels. These might include elements of established programs a representative German family sample during COVID-19 lock-
such as mindfulness-based cognitive therapy, dialectical behavioural down, compared with pre-COVID-19 conditions. It thus adds
therapy or acceptance-based behavioural therapy.38 Moreover, activ- knowledge to the current evidence base on the psychological
ity-based interventions, such as yoga, sports, play and creative arts, impact of this worldwide pandemic. Our findings have several
have been shown to improve mental health, and might be promising implications for clinicians, researchers, policy makers and social
in providing helpful offers for adolescents to spend time outside the actors. As the COVID-19 pandemic continues, psychological
home without violating restriction rules.39 Online interventions stress and its corresponding threat to mental health should be of
might be a useful new method to support mental health,20 especially greater consideration among public health authorities. Besides pro-
during a time where personal contacts are limited. tecting the population from the disease, adolescents and their
parents – especially mothers – could benefit from targeted psycho-
logical stress prevention measures. The identification of sociodemo-
Strengths and limitations graphic, family-associated and potentially modifiable psychological
The study has numerous strengths, including the use of prospective risk factors, such as capacity for adaptive coping, provides decision
data with an assessment just before the pandemic and during makers with meaningful insights for public health action.
COVID-19 lockdown; a large study population representative Future studies should focus on the detailed investigation of
regarding gender (most of the studies available have included a sig- factors explaining individual increased psychological stress and
nificant higher proportion of female respondents), age and region of resiliency. Although the present study could not identify adoles-
living; the data of parent–child dyads; information on potential risk cents’ age as a significant covariate regarding psychological stress,
factors before the COVID-19 pandemic and the variety of standar- future research should investigate age aspects in more detail by
dised subjective ratings to collect data on psychological stress and including younger children and their parents. Moreover, cross-cul-
potential psychological risk factors. However, several limitations tural studies should enhance knowledge on the comparability of the
of this study need to be considered. presented findings. Psychological stress variability during the course
First, although sample representativity was warranted in terms of of the pandemic should be investigated by follow-up measurements.
age, gender and place of residence, representativity in other respects
might have been reduced because of the data collection procedure. In
Kerstin Paschke , MD, German Center for Addiction Research in Childhood and
this respect, the sample only includes households with sufficient Adolescence, University Medical Center Hamburg-Eppendorf, Germany;
knowledge of the German language, so families with an immigrant Nicolas Arnaud, PhD, German Center for Addiction Research in Childhood and
Adolescence, University Medical Center Hamburg-Eppendorf, Germany; Maria
background might not have been properly taken into account. In add- Isabella Austermann, MSc, German Center for Addiction Research in Childhood and
ition, around 5% of German households do not have internet access40 Adolescence, University Medical Center Hamburg-Eppendorf, Germany;
and could not be included in this study. Moreover, although online Rainer Thomasius, MD, German Center for Addiction Research in Childhood and
Adolescence, University Medical Center Hamburg-Eppendorf, Germany
questionnaires are highly valued for cost-effectiveness in large epi-
Correspondence: Kerstin Paschke. Email: k.paschke@uke.de
demiological studies, missing data is a common problem, especially
when investigating dyads and children. Accordingly, 113 parent– First received 20 Sep 2020, final revision 12 Feb 2021, accepted 1 Apr 2021
child dyads had to be omitted from subsequent analysis, which
might have decreased representativity. In addition, all participants
were asked to complete the questionnaire independently, but the
influence of others cannot be excluded. Supplementary material
Second, although our study revealed a significant increase in
Supplementary material is available online at https://doi.org/10.1192/bjo.2021.49.
psychological stress in families on a population level, and identified
risk factors during the first German COVID-19 lockdown, it could
not explain the individual circumstances that may have preceded Data availability
these increases. In fact, we cannot rule out the possibility that The data that support the findings of this study are available from the corresponding author,
other factors or unknown third variables during the survey interval K.P., upon reasonable request, after all results of the parent–child survey have been published.
contributed to the variance in the prospective psychological stress
change. Moreover, we cannot conclude on the individual factors Acknowledgements
that actually led to the observed increases in psychological stress,
We thank Dr Peter-Michael Sack for his support on preparing the manuscript, Dr Torsten
because of the restricted number of items in an online survey, Wüstenberg for valuable discussions on the initial data analysis strategies, and Milan
such as the number of critical life events, family members affected Röhricht for his language-editing support.
6
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18 Cartwright M, Wardle J, Steggles N, Simon AE, Croker H, Jarvis MJ. Stress and
Author contributions dietary practices in adolescents. Health Psychol 2003; 22(4): 362–9.
K.P. and R.T. conceptualised and designed the study, and decided to publish the paper. K.P. 19 Demkowicz O, Panayiotou M, Ashworth E, Humphrey N, Deighton J. The factor
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authors critically revised the draft for important intellectual content. All authors agreed to be
accountable for all aspects of the work in ensuring that questions related to the accuracy or 20 Harrer M, Adam SH, Baumeister H, Cuijpers P, Karyotaki E, Auerbach RP, et al.
integrity of any part of the work are appropriately investigated and resolved. All authors Internet interventions for mental health in university students: a systematic
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21 R Core Team. R: A Language and Environment for Statistical Computing.
Funding R Foundation for Statistical Computing, 2019 (https://www.R-project.org/).
22 Davis MT, Holmes SE, Pietrzak RH, Esterlis I. Neurobiology of chronic stress-
The current study is part of a parent–child survey that was financially supported by the German
health insurance company DAK Gesundheit. The funding was awarded to the German Center related psychiatric disorders: evidence from molecular imaging studies.
for Addiction Research in Childhood and Adolescence (K.P. and R.T.). The supporters had no Chronic Stress 2017; 1: 2470547017710916.
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writing of the manuscript.
sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic
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